Fillable BUILDING PERMIT APPLICATION CONTACT INFORMATION PROPERTY INFORMATION PROJECT (City of Oxnard)

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BUILDING PERMIT APPLICATION CONTACT INFORMATION PROPERTY INFORMATION PROJECT (City of Oxnard)

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  • 30 check-boxes
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PROJECT ADDRESS
TRACT LOT NO. UNIT NO.
PROPERTY OWNER NAME
CONTACT NAME
CONTACT ADDRESS CITY ZIP
PHONE
E-MAIL
APN
PHONE E-MAIL
BTC#
PHONE E-MAIL
BTC#
PROPERTY INFORMATION
SCOPE OF WORK
PLUMBING
Describe what is being built and its use below and attach a site plan identifying proposed work.
Describe or detail additional information or specifications below.
CONTACT INFORMATION
APPLICATION NUMBER
PROJECT VALUATION
EXISTING DWELLING SQUARE FOOTAGE: EXISTING GARAGE SQUARE FOOTAGE : NUMBER OF STORIES:
INDICATE # OF APPLICABLE PLUMBING FIXTURES BELOW:
BATH/SHOWER:
LAUNDRY
WASHER:
DISH
WASHER:
GARBAGE
DISPOSAL:
LAVATORY:
BATHROOM
SINK:
KITCHEN
SINK:
SHOWER
PAN:
DRAIN:
WATER
HEATER:
SEWER:
GREASE
TRAP:
SAMPLE
WELL:
LAWN
SPRINKLER:
WATER
SYSTEM:
BACK FLOW
DEVICE:
GAS/FUEL
OUTLET:
POOL/SPA
ABOVE GROUND:
TOILET/URINAL:
POOL/SPA
INDOOR:
LAUNDRY
TRAY:
OTHER:
MECHANICAL
INDICATE # OF MECHANICAL ITEMS BELOW:
HEATING
SYSTEM:
AC
SYSTEM:
EVAP
COOLER:
AIR
HANDLER:
EXHAUST
FAN:
HOODS: OTHER:
PROCESS
PIPING:
HAZARDOUS:
NON-
HAZARDOUS:
GAS:
SIGNS
INDICATE # OF MECHANICAL ITEMS BELOW:
NON-ILLUMINATED
ILLUMINATED
CIRCUITS:
NO: TYPE:
SIGN AREA
(SF):
PROJECT INFORMATION
AUTHORIZATION
BUILDING PERMIT
APPLICATION
ELECTRICAL
INDICATE # OF ELECTRICAL ITEMS BELOW:
OUTLETS:
SWITCHES:
POOL:
OTHER:
SPA:
SERVICE & SUB PANELS TEMPORARY POWER MOTORS TRANSFORMERS
AMPS:
NO.:
NEW SERVICE?:
MAIN:
SUB:
TYPE:
NO:
H.P:
NO:
SIZE:
GENERATORS
NO:
WATTS:
FIRE PERMITS
NEW
TENANT IMPROVEMENT
UNDERGROUND LENGTH: OVERHEAD AREA (SF):
SPECIAL CONDITIONS
FIRE SUPPRESSION SYSTEM FIRE ALARM SYSTEM NO. OF ALARM DEVICES:
ROOF PERMITS
ROOF AREA:
ROOF COVERING CLASS:
NEW
ZONING
PLANNING
BUILDING
PLANNING
FIRE
ELECTRICAL
PARKS
SOURCE CONTROL
APPROVALS
CONSTRUCTION
TYPE:
OCCUPANCY
GROUP:
MAX
OCCUPANCY:
STORIES:
UNITS:
BEDROOMS:
REQUIRED
PERMIT APPROVED FOR ISSUANCE:
DATE
APPROVED
BY
REMARKS
ADDITION
ALTERATION
PATIO COVER
ROOF PITCH (in 12 inches): LAYERS OF PAPER: GRADE #:
A
DRIP EDGE SIZE:__________ X __________
B
REPAIR
ISSUED BY:
MOVE
DEMOLITION
PATIO COVER
FENCE
RE-ROOF
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
RETAIL
OFFICE
RESTAURANT
INDUSTRIAL
MEDICAL
NEW BUILDING
SQ. FT.
DECK/PATIO
SQ. FT.
ADDITION
SQ. FT.
EXISTING
DWELLING
SQ. FT.
REMODELED
SQ. FT.
PATIO COVER
SQ. FT.
______________
INSTITUTIONAL
PUBLIC
SINGE-FAMILY
MULTI-FAMILY
HOTEL/MOTEL
City of Oxnard Service Center
214 S C Street, Oxnard CA 93030
www.oxnard.org/build 805 385-7925
I certify that I have read this application and declare under perjury that the information contained herein is true, correct, and complete. I agree to comply with all city and county
ordinances and state laws relating to building construction, and hereby authorize representativesof the city to enter upon the above mentioned property for inspection purposes. I
am the owner of the structure listed on this permit or I represent the owner and am acting with the owner’s full knowledge and consent.
________________________________ ____________________________________________________ _______________________________
Date Owner / Contractor Authorized Signature Title
FOR CITY OFFICE USE ONLY
CLASS
OF WORK
USE OF
BUILDING
RESIDENTIAL COMMERCIAL
TENANT
IMPROVEMENT
SQ. FT.
ACCESSORY
SQ. FT.
--------------------
OTHER SQ. FT.
--------------------
OTHER SQ. FT.
POLE PEDESTAL
LIGHT FIXTURES:
Executed at City of Oxnard:
CONTRACTOR / COMPANY NAME
COMPANY ADDRESS
CITY ZIP
STATE LICENSE#
PHONE E-MAIL
BTC#
ARCHITECT / ENGINEER / COMPANY NAME
COMPANY ADDRESS
CITY ZIP
STATE LICENSE#
All general contractors, sub-contractors, architects, engineers, designers, and others conducting business with the City of Oxnard are
required to maintain a current business license -Business Tax Certificate (BTC) For more information Contact Licensing Services (805) 385-7817
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CALBO Jan 1, 2009 Permit Application Template
B109 Construction Permit Application – Signature Form V-1-1.doc v1-1.doc
C
ITY OF
O
XNARD
Community Development- Building and Engineering
CONSTRUCTION PERMIT APPLICATION
PERMIT #
APN
_____-__________ Signatures Not Completed in the Presence of Department Staff Must be Notarized __________________
#1
IDENTIFY YOUR BUILDING PROJECT
Property Location or Address: _________________________________________________________________________________
This permit is to be issued in the name of the (_) Licensed Contractor or (_) the Property Owner as the permit holder of record
who will be responsible and liable for the construction.
Property Owner Information: Name __________________________________ Tel No______________________________________
Mailing Address ______________________________________________________________________________________________
Licensed Design Professional (Architect or engineer in charge of the project) Information:
Name _________________________________ License No.__________________ Tel No____________________________________
Mailing Address ______________________________________________________________________________________________
Description and valuation of work to be performed: _________________________________________________________________
#2
IDENTIFY WHO WILL PERFORM THE WORK (Complete either 2a or 2b)
2a – CALIFORNIA LICENSED CONTRACTOR’S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division
3 of the Business and Professions Code, and my license is in full force and effect.
Contractor Name and Address: __________________________________________________________________________________
License Class and No. ___________________________ Contractor Signature _____________________________________________
2b – OWNER-BUILDER’S DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors’ State License Law for the reason(s) indicated below
by the checkmark(s) I have placed next to the applicable item(s) (Section 7031.5, Business and Professions Code: Any city or county
that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant
for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors’ State License Law
(Chapter 9) (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt from
licensure and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the
applicant to a civil penalty of not more than five hundred dollars ($500).):
(_) I, as owner of the property, or my employees with wages as their sole compensation, will do (_) all of or (_) portions of the
work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The Contractors’ State
License Law does not apply to an owner of property who, through employees’ or personal effort, builds or improves the property,
provided that the improvements are not intended or offered for sale. If, however, the building or improvement is sold within one
year of completion, the Owner-Builder will have the burden of proving that it was not built or improved for the purpose of sale.).
(_) I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section 7044,
Business and Professions Code: The Contractors’ State License Law does not apply to an owner of property who builds or improves
thereon, and who contracts for the projects with a licensed Contractor pursuant to the Contractors’ State License Law.).
(_) I am exempt from licensure under the Contractors’ State License Law for the following reason:
CALBO Jan 1, 2009 Permit Application Template
B109 Construction Permit Application – Signature Form V-1-1.doc v1-1.doc
By my signature below I acknowledge that, except for my personal residence in which I must have resided for at least one year prior
to completion of the improvements covered by this permit, I cannot legally sell a structure that I have built as an owner-builder if it
has not been constructed in its entirety by licensed contractors. I understand that a copy of the applicable law, Section 7044 of the
Business and Professions Code, is available upon request when this application is submitted or at the following Web site:
http://www.leginfo.ca.gov/calaw.html.
Property Owner or Authorized Agent signature________________________________________________ Date ________________
***Signatures Not Completed in the Presence of Department Staff Must be Notarized
#3
IDENTIFY WORKERS’ COMPENSATION COVERAGE AND LENDING AGENCY
WARNING: FAILURE TO SECURE WORKERS’ COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY’S FEES.
WORKERS’ COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
(_) I have and will maintain a certificate of consent to self-insure for workers’ compensation, issued by the Director of Industrial
Relations as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Policy
No. _______________________________________________________________________________________
(_) I have and will maintain workers’ compensation insurance, as required by Section 3700 of the Labor Code, for the performance
of the work for which this permit is issued. My workers’ compensation insurance carrier and policy number are:
Carrier__________________________ Policy No_______________________ Expiration Date_____________
Name of Agent ____________________________________________ Tel No __________________________
(_) I certify that, in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as
to become subject to the workers’ compensation laws of California, and agree that, if I should become subject to the workers’
compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions.
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the
work for which this permit is issued (Section 3097, Civil Code).
Lender’s Name and Address_____________________________________________________________________________________
____________________________________________________________________________________________________________
#4
DECLARATION BY CONSTRUCTION PERMIT APPLICANT
By my signature below, I certify to each of the following:
I am (_) a California licensed contractor or (_) the property owner* or (_) authorized to act on the property owner’s behalf**.
I have read this construction permit application and the information I have provided is correct.
I agree to comply with all applicable city and county ordinances and state laws relating to building construction.
I authorize representatives of this city or county to enter the above-identified property for inspection purposes.
*requires separate verification form
California Licensed Contractor, Property Owner* or Authorized Agent**: **requires separate authorization form
Signature ___________________________________________________ Date ______________________________
***Signatures Not Completed in the Presence of Department Staff Must be Notarized
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CALBO Jan 1, 2009 - Owner Builder Packet.doc 1 of 2
PERMIT #
____-___________
CITY OF OXNARD
Development Services - Building and Engineering
APN _______________
PROPERTY OWNER’S PACKAGE
Signatures Not Completed in the Presence of Department Staff Must be Notarized
Disclosures & Forms for Owner-Builders Applying for Construction Permits
IMPORTANT! NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the
property improvements specified at ____________________________________________________________.
We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you
aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the
Owner-Builder. We will not issue a building permit until you have read, initialed your understanding of
each provision, signed, and returned this form to us at our official address indicated. An agent of the
owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting
authority.
OWNER’S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
DIRECTIONS: Read and initial each statement below to signify you understand or verify this information.
____1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an “Owner-
Builder” building permit that erroneously implies that the property owner is providing his or her own labor and
material personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any
injuries sustained by an unlicensed person and his or her employees while working on my property. My
homeowner’s insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder
and am aware of the limits of my insurance coverage for injuries to workers on my property.
____2. I understand building permits are not required to be signed by property owners unless they are
responsible for the construction and are not hiring a licensed Contractor to assume this responsibility.
____3. I understand as an “Owner-Builder” I am the responsible party of record on the permit. I understand that
I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his
or her name instead of my own.
____4. I understand Contractors are required by law to be licensed and bonded in California and to list their
license numbers on permits and contracts.
____5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors,
and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may
be considered an “employer” under state and federal law.
____6. I understand if I am considered an “employer” under state and federal law, I must register with the state
and federal government, withhold payroll taxes, provide workers’ compensation disability insurance, and
contribute to unemployment compensation for each “employee.” I also understand my failure to abide by these
laws may subject me to serious financial risk.
____7. I understand under California Contractors’ State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed
by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of
the work is performed under contract with a licensed general building Contractor.
CALBO Jan 1, 2009 - Owner Builder Packet.doc 2 of 2
____8. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable
for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent
construction defects in the workmanship or materials.
____9. I understand I may obtain more information regarding my obligations as an “employer” from the Internal
Revenue Service, the United States Small Business Administration, the California Department of Benefit
Payments, and the California Division of Industrial Accidents. I also understand I may contact the California
Contractors’ State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information
about licensed contractors.
____10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand
that I am the party legally and financially responsible for proposed construction activity at the following address:
_________________________________________________________________________________________
____11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will
abide by all applicable laws and requirements that govern Owner-Builders as well as employers.
____ 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated by laws designed to protect the
public. If you contract with someone who does not have a license, the Contractors’ State License Board may be
unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against
unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed
Contractor or employee of that individual or firm is injured while working on your property, you may be held
liable for damages. If you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible
for verifying whether or not those Contractors are properly licensed and the status of their workers’
compensation insurance coverage.
Before a building permit can be issued, this form must be completed and signed by the property owner
and returned to the agency responsible for issuing the permit. Note: Signatures Not Completed in the
Presence of Department Staff Must be Notarized.
Signature of property owner ___________________________________________ Date: __________________
__________________________________________________________________________
Note: The following Authorization Form is required to be completed by the property owner only when
designating an agent of the property owner to apply for a construction permit for the Owner-Builder.
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER’S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I
hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents
necessary to obtain an Owner-Builder Permit for my project.
Scope of Construction Project (or Description of Work): ____________________________________________
Project Location or Address: _________________________________________________________________
Name of Authorized Agent: _________________________________________Tel No ___________________
Address of Authorized Agent: _________________________________________________________________
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled
out the above information and certify its accuracy. Note: Signatures Not Completed in the Presence of
Department Staff Must be Notarized.
Property Owner’s Signature: _______________________________________ Date: _____________________
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BUILDING PERMIT APPLICATION CONTACT INFORMATION PROPERTY INFORMATION PROJECT (City of Oxnard)

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Completed 31 January 2021

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